Study design and setting
This was a community based cross-sectional descriptive study carried out in the Abong-Mbang Health District, Upper Nyong Division of East Cameroon. The Abong-Mbang Health District is located in the south eastern rain forest of Cameroon which is part of the rainforest of Central Africa, where most Ebola virus disease outbreaks except the 2014 West African outbreak originated [7, 28].
The Abong-Mbang has an estimated population of about 28,904 inhabitants and covers an area of about 15.000 km2. It is made of 92 villages that are grouped into 8 health areas, Mindourou, Nkouak, Mbomba, Angossas, Ankoung, Atok, Abong-Mbang North and Abong-Mbang South (Fig. 1) [29] and has 25 public and private health facilities. It has a wet equatorial climate (also known as a Guinea type climate). Its forest has abundant and diverse animal life with animals such as monkeys, some of the last populations of gorillas and chimpanzees [28]. Fruit and insectivorous bats and birds of various species are also common, as are various rodents.
Figure 1: Map of Abong-Mbang Health District showing various health areas
Source: [29]
Study Population
The study population comprised of the Baka community of Abong-Mbang Health District. The Baka people (formerly called the Pygmies) are an ethnic group inhabiting the southeastern rain forests of Cameroon, northern Republic of the Congo, northern Gabon, and southwestern Central African Republic and Western Equatorial state of South Sudan. The Baka community of Abong-Mbang Health District is made up of 24 villages: Ampele, Andoa, Aviaton, Bitsoman, Cyrie, Djibot, Dympam, Diassa, Elandjoh, Kendjo, Madouaite, Mapela, Mayos, Mballam, Mbang, Mbiatoh, Mengang, Menzoh, Missoume, Moangong, Nombakele, Petit Paris, Plateau and Sombou. Out of the 24 villages in Abong-Mbang, our study involved 13 villages. A small proportion of Bantu people also reside in this area. Almost the entire Baka population is semi-sedentarised, spending part of the year in their roadside settlements and go for short- and long-term (up to several months) hunting and gathering expeditions deep into the forest. Most of them rely almost exclusively on traditional health care [30].
Inclusion and Exclusion Criteria
Individuals aged ≥18 years who have resided for at least 5 years in the Baka community of Abong-Mbang Health District, and who granted consent to participate in the study were recruited. Those who denied consent/assent, were <18 years old or had lived in the community for less than 5 years were excluded.
Sampling and sample size determination
A multi-stage cluster sampling technique was used. Of the 24 villages of the Baka community 13 were randomly selected. From each of these villages, household heads or their representatives were recruited by systematic random sampling.
[Please see the supplementary files section to view the equations.]
Sample collection and analyses
Data was collected by trained research assistants using a pre-tested semi-structured questionnaire adapted from the risk factors involved in the Health Promotion Theory and then developed according to the objectives of the study. The questionnaire was divided into four sections: demographics, an assessment of participants’ knowledge on Ebola, their feeding habits and practices, and their health seeking behavior as contributory factors to exposure to Ebola.
Data was entered into EPI Info 7, cleaned and analyzed using SPSS version 20.0. The relationship between the study outcome and the independent variable was analyzed using the chi-square test. An adapted 8 item Morisky Scale was used to assess level of knowledge of the symptoms and transmission of Ebola. Participants who could list 4-8 correct manifestations or routes of transmission were considered to have good knowledge; those with 2-3 correct manifestations had fair knowledge and those who had one or none correct had poor knowledge.
An adapted Threat Capability Basic Risk Assessment Guide [31] was used to assess the level of risk involved in consuming bush meat. This guide had four different levels of assessment: very high, high, moderate and low. Participants who consumed all six animals listed (Fruit bats, chimpanzees, gorillas, bush pigs, monkeys, forest Antelopes, and Porcupines) were considered to be at a very high risk, 4-5 animals at high risk, 2-3 animals at moderate risk and 0-1 animal at low risk.
Ethical considerations
Ethical approval was obtained from the Centre Regional Ethics Committee for Human Health Research (No: CE031/CRERSHC) of the Ministry of Public Health, Cameroon. Administrative approval was obtained from the Regional Delegation of Public Health for the East Region. Informed consent was obtained from every participant prior to collection of data. Participants 21 years and above granted consent to participate in the study. For those <21 years old, consent was obtained from their parent/guardians. Interviews were conducted in private. Questionnaires were assigned codes instead of writing the name of the participants. The original questionnaire which was in English was translated to French. Data collectors were French speaking with three of them also serving as translators as they could speak the Baka language.